February 24th, 2009 by Dr. Val Jones in Health Policy, Medblogger Shout Outs, Opinion
Tags: AHRQ, CMS, Healthcare reform, Hospital Compare, Medicare, Protocol, White Coat's Call Room
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As far as I can tell, there are very few physicians currently involved in the innermost circles of healthcare reform. This is concerning to me, not because I’m one of those “paternalistic doctors” who “drive up in their Porsches threatening to pull out of Medicare” but because I think that many policy makers don’t really understand the incredible complexity associated with doing the right thing for patients. Here is an excerpt from the WhiteCoat’s Call Room blog that perfectly illustrates why practicing good medicine often requires a break from protocol:
It isn’t just the patients who think I’m a bad doctor.
Based on the information from all the pinheads at Medicare’s “HospitalCompare” web site, I’m downright dangerous.
For those who don’t know about Hospital Compare, it is a site where the general public can compare the “quality indicators” for hospitals on measures deemed important by the AHRQ.
I failed to meet a couple of indicators recently, so I received notices from our hospital administration that I am now considered out of compliance with the HospitalCompare guidelines and am bringing down our numbers on the HospitalCompare.gov web site.
In other words, Medicare thinks I’m a bad doctor.
Let me tell you about the patients I screwed up on.
The first patient was a gentleman in his 70’s who started having chest pain at home. He got sweaty, passed out, and hit his head on the concrete floor in his house, causing a nice goose egg on the back of his noggin. When he arrived in the emergency department, he was still having chest pain, so we hooked him up to an EKG and … lo and behold … he was having a myocardial infarction.
According to the quality indicators at “HospitalCompare”, if a patient with a heart attack is going to receive thrombolytics (”clot busters”), the thrombolytics must be given within 30 minutes of the patient’s arrival at the hospital. If a health care provider takes longer than 30 minutes to administer thrombolytics to someone with a heart attack, the government considers that provider to be practicing bad medicine.
Now I’m faced with a choice:
A. Do I give clot busters to someone who sustained a significant head injury (and may be bleeding internally) so that I can look like a “good doctor” to Medicare and HospitalCompare.hhs.gov? If there is bleeding inside his brain, clot buster medications will make the bleeding worse and could kill him.
-OR-
B. Do I perform a CT scan on the patient to make sure that there is no bleeding inside his brain before I give the clot-buster medications? If I do the CT scan, there is no way that we’ll get the results and be able to give the patient thrombolytics within the 30 minute window.
If I choose “A,” the hospital stays in the upper echelon of facilities that meet HospitalCompare.hhs.gov’s guidelines. Doesn’t matter if the patient dies – according to Medicare, “We’re Number ONE!”
If I choose “B” I’m doing what is right for the patient, but our hospital will look bad and HospitalCompare.hhs.gov will plaster it all over the internet that our hospital doesn’t follow Medicare’s rigid and sometimes life-threatening guidelines.
I chose “B.”
According to HospitalCompare.hhs.gov, my decision made me a bad doctor…
February 22nd, 2009 by Dr. Val Jones in Medblogger Shout Outs
Tags: Best Of, Blogger, Heard Around The Blogosphere, Humor, Medblogger, Weekly
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I thought I’d highlight some interesting posts written by my peers this week. Keep up the great blogging, everyone!
Healthcare Policy
This is what happens when you begin the process of bailing out key stakeholders in our economy: h/t Happy Hospitalist
Britain’s NHS has hired teams of bureaucrats whose sole purpose is to enforce health coverage denials. Dr. Crippen also notes that the NHS will cover sex change operations, but not ear repair from piercings.
The number of Americans without health insurance is increasing by 14,000/day. H/t Shadow Fax.
Just Plain Gross
Thanks to Medgadget for featuring a story on grey nurse sharks. Apparently their young, while still in the womb, cannibalize each other until only one is left in the uterus. They even linked to a video of fetal sharks devouring one another. Eww!
Bad Science Of The Week
Thanks to Mark Hoofnagle for deconstructing the laughable PLoS article suggesting that cell phone exposure increases migraine risk but decreases Alzheimer’s and epilepsy risk. The study was a statistical fishing expedition that proposes random cause and effect.
Good Doctor
Dr. Theresa Chan coaxed a 90 year old man out of somnolent delirium by singing to him.
“Bad Doctor”
By not caving in to a 16 year old’s request for a medical excuse from school or admitting a patient to the hospital for walker training and observation, this doctor won no brownie points with his patients.
Funny Patient
Nurse Gina witnesses a post-op patient give a doctor a math lesson.
Tragedy
A physician mother struggles with the immanent death of her 4-year-old with brain cancer.
February 10th, 2009 by Dr. Val Jones in Health Policy, Medblogger Shout Outs, Opinion
Tags: CMS, Dr. Rich Fogoros, Dr. Rob Lamberts, Dr. Val Jones, Fixing American Healthcare, Fraud, Medicare, Physicians, RAC, Recovery Audit Contractor, Spanish Inquisition
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Dr. Rob Lamberts does an admirable job explaining why physicians are worried about the Recovery Audit Contractor (RAC) approach to identifying Medicare fraud. Complying with Medicare coding and billing rules is so difficult that physicians regularly resort to undercharging for their services, just to avoid the perception of fraudulent practices. Any medical practice that bills more than average is potentially subject to RAC audit, and the auditors themselves are paid a commission for finding “fraud.” In many cases, the “fraud” amounts to insufficient documentation of appropriate and necessary work performed by the physician.
Dr. Rob writes:
The complexity of E/M coding makes it almost 100% likely that any given physician will have billing not consistent with documentation. Those who chronically undercoded (if they are still in business) are at less risk than those who coded properly. Every patient encounter requires that physicians go through an incredibly complex set of requirements to be paid, and physicians like myself have improved our coding level through the use of an EMR. This doesn’t necessarily imply we are over-documenting, it simply allows us to do the incredibly arduous task of complying with the rules necessary to be paid appropriately.
Have I ever willingly committed fraud? No.
Am I confident that I have complied with the nightmarish paperwork necessary to appropriately bill all of my visits? No way.
Am I scared? You bet. The RAC will find anything wrong with my coding that they can – they are paid more if they do.
Dr. James Hubbard writes:
It would be fine if they were truly looking for fraud and abuse, but they look for some technicality or just a different interpretation. Forget about any recourse. A few years ago, I was asked to pay Medicaid back $5000. I protested they were completely wrong with their interpretation of their findings. The auditors said I had to pay it, but could argue for a refund by sending forms and proof to the “review committee”. I did that and received a reply that the $5000 was too small for the review committee to take up. I stopped taking Medicaid.
Sounds like the Spanish Inquisition, doesn’t it?
***
For more excellent analysis of the subject, I strongly recommend Dr. Rich Fogoros’ recent book: Fixing American Healthcare.
January 22nd, 2009 by Dr. Val Jones in Medblogger Shout Outs
Tags: Obstetrics And Gynecology, Peggy Polaneczky, Quote of the day, TBTAM
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My friend and fellow medblogger Peggy Polaneczky, MD had this to say after returning from a medical conference in Salzburg:
We had lots of conversations about healthcare in our respective countries. And all I can say is, despite all the issues we have in the United States, I wouldn’t want to be practicing medicine anywhere else but here. Not when I hear tale of docs whose only way of surviving financially is to take tips from patients who pay to squeeze into the surgical schedule ahead of the cue. Or of abdominal emergencies handled in hospitals that don’t have a CT scanner. And not a single fellow has a microscope in their office, forcing them to rely on gram stain only for management of vaginitis. (A poor substitute for an in office wet prep in my opinion.)
Most of these docs would give their eye teeth to spend some time learning medicine in the United Sates, be it something as simple as an observership or as complex as a second residency. Unfortunately, visa regulations in their countries and ours make this extremely difficult. But all of them will be offered observerships in Vienna and in Germany at the Institute’s expense.
January 13th, 2009 by Dr. Val Jones in Announcements, Medblogger Shout Outs
Tags: Barack Obama, Best Of The Medical Blogosphere, Better Health, Dr. Val Jones, Grand Rounds, Grand Rounds 5:18, Health Care Reform, Healthcare reform, Inauguration, January 20th, Medical Blogs, MedPageToday, Tom Daschle, Weekly Summary, www.getbetterhealthc.om
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Dr. Val is hosting the historic inauguration day Grand Rounds at MedPageToday. Please send your submissions to this email address: valjonesmd AT gmail dot com. Put “Grand Rounds Submission” in your email title and please use this format for the body of your email:
- Post title
- Post url
- Short description of the post
- Blog title
- Blog url
Although I have never done a themed Grand Rounds before, it would be terribly remiss of me not to acknowledge healthcare reform on the very inauguration day of our new President, Barack Obama. So please send me your best posts about the change you’d like to see in healthcare. If we do a really great job of this, maybe Tom Daschle will take a looksie? Don’t laugh, but DC is a small world – I share a hair stylist with Tom’s wife, Linda!
Please send me your submissions by midnight, ET, Sunday January 18th. I will include all submissions, but will give more weight to those that are about healthcare reform.
For those of you who are reading this and wondering what on earth I’m talking about – please read about Grand Rounds here. It’s the weekly summary of the best blog posts from the medical blogosphere.
My inaugural Grand Rounds will be published at MedPageToday at 8am, Tuesday, January 20th. (This link will work from that time on). I hope that we’ll reach an unprecedented number of readers on this platform.
I look forward to receiving your submissions!
Warmest Regards,
Val
P.S. Please enjoy Barbara Kivowitz’s Grand Rounds this week – it has a Sci Fi theme! The January 27th edition of Grand Rounds will be hosted by: Chronic Babe.
